Intake & Consent Form

Parental Consent Form (#15)

Parental / Guardian Consent Form for Adolescent/Child Therapy Services




Terms & Conditions


By signing this form, you accept the terms and conditions below and agree to the conditions for the therapy services provided by your therapist for my nominated child/adolescent. 

Counselling is an interactive process where your child has the opportunity to explore issues of concern to them under the guidance of a trained and experienced therapist who assists you in identifying unhelpful patterns and contributing factors, underlying causes, and who works with them to develop helpful strategies and more useful ways of looking at these concerns to alleviate distress and aid in the development of greater emotional and personal well-being.

While most clients find counselling immensely beneficial and life-changing, success cannot be guaranteed and largely depends on how open you are, how committed you are to therapy, how hard you are prepared to work and how committed you are to change.

Counselling is a process that leads you to look at life’s challenges and personal issues closely and, as such, can have risks associated with it due to the exposure to, at times, intense and difficult feelings and thoughts being explored.

These risks may include a wide range of strong emotions and thoughts, feeling tired or drained, headaches, nausea, or other physical and emotional symptoms, feelings of abandonment from others or even your therapist. If you child experiences any of these symptoms at any time, they are encouraged to share this with me during the session.

Sessions are be 45-50 minutes long. Except the first one, which is 80 minutes

The remainder of the hour is used by the counsellor to begin required documentation, background research and treatment planning for their process with you.


For communication between sessions, we only use email communication and text messaging for administrative purposes only. 

This also means that email exchanges and text messages with my office should be limited to administrative matters. 

This includes things like setting and changing appointments, billing matters, and other related issues.

You should be aware that we cannot guarantee the confidentiality of any information communicated by email or text. Therefore, we will not discuss any clinical information by email or text and ask that you do not either. We do not "check-in" with client's outside of session times. If your child is experiencing challenges that you feel I should be aware, please send me an email or sms me. However as a general rule, it's best to have your child bring these things up with me in therapy.

This also serves to ensure that the therapeutic relationship stay within the boundaries of the therapy session, and that there is no misunderstanding that your therapist doesn't care. Please refer to  discharge policy below for more on this.

Please note, we will try and get back to you within 24 hours (except weekends / holidays). We do not regularly check work email or texts, and we do not respond immediately, so these methods should not be used if there is an emergency.

Please note: Sessions are coordinated with the child. This means, bookings, cancellations, future appointments, rescheduling is to be done by your child.


Counsellors who work with adolescents/children have the difficult task of protecting the adolescent’s/child's right to privacy while at the same time respecting the parent's or guardian's right to information. Therapy is most effective when a trusting relationship exists between the counsellor and the adolescent/child. Privacy is especially important in securing and maintaining that trust. In our practice, we provide individual counseling to adolescents/children.

To ensure a child’s privacy we will not provide detailed information to the parent/caregiver regarding what the child shared unless the child provides consent.

Instead, general themes, ideas and recommendations can be provided as well as support and encouragement to the parent/caregiver. If it is necessary to refer your child to another mental health professional with more specialized skills, we may share that information with them if required. 

It is important for your child's therapist to collect this information as it forms a necessary part of the psychological assessment and treatment that is conducted.

What they discuss in the counselling sessions is private and confidential. As such, the therapist requires your written permission to speak to a third party (e.g.: your doctor) about their treatment.

In signing this form we ask the Parents/Guardians to understand that the service we offer children also respects their right to privacy

There are only three exceptions to this:

1) if there is a risk of harm to you or to someone else and
2) if a court of law subpoenas documentation.
3) Supervision

While therapists do keep records about your treatment which are securely kept under lock and key with only your therapist having access to this record.

Psychologists and psychotherapists are bound by the Australian Psychological Society’s Code of Ethics, PACFA, ACA and current Privacy Legislation.

All of the above exceptions to confidentiality are extremely rare, but it's important for you to be aware of these limitations of confidentiality under exceptional circumstances.

In regards to Supervision, therapists and counsellors may sometimes record sessions and discuss your case with a registered supervisor. This can dramatically help the therapist in working more effectively with you. However, we also understand that some clients may not want this extra support and may want to opt out of this. If you would like to opt out, please advise your therapist.


An 80min session is $220

50 minutes is $160

Please note NDIS incurs an additional $44 (this covers additional supervision)


  • Online therapy sessions  is not a crisis based clinical service.
  • Online psychotherapy may not be appropriate for clients with active suicidal or homicidal thoughts, or clients who are experiencing acute mental health problems, such as manic or psychotic symptoms.
  • It is the responsibility of the client to inform their therapist if they are at risk of harm to self or others.
  • If through the intake evaluation or subsequent psychotherapy sessions, a client is deemed to be at risk of harm to self or to others, an assessment is made to determine if online therapy is still appropriate
  • If a client who was not formerly at risk, should become at risk of such harm to self or others, they must immediately report it to their therapist. In such cases, a client may be referred to a traditional non-online counselling program or provider.


By signing this form you are providing your authority to charge your valid credit card or withhold part or all of your deposit in the event of any cancellation fees being incurred under our cancellation policy.

We will only charge your card or withhold your deposit if you incur a cancellation fee under the terms of the cancellation policy (or, with your prior approval, for any other amount payable).

If you believe your account has been debited incorrectly you should contact us immediately. If we find that your account has been incorrectly debited we will issue a credit card refund accordingly. We will confirm the amount of the refund in writing. If we find your account has not been incorrectly debited we will provide you with reasons and evidence in writing.


A minimum of 24 hour notice is required to cancel or reschedule an appointment, otherwise the full fee of the session will be charged. 

You can read more about the cancellation policy here

Clients are required to make any changes to bookings using the online dashboard


A client becomes discharged from our practice when a session hasn't been booked for 4 weeks by the client. To reengage services with our practice, it is the client's responsibility to reach out and book in again, as we do not engage in "ambulance chasing".


Your therapist will develop strategies and a plan with you to assist in the management of a crisis if you are at risk and if this is appropriate as part of your treatment.

However, we are a private counselling practice and, as such, are not equipped to offer crisis services.

In case of an emergency or crisis, please contact triage at your local hospital or Lifeline on Ph: 131 114.

Online Counselling via Zoom or Google Meets Zoom is a secure (encrypted) video conferencing system, and is virtually impossible for anyone to intercept and decrypt the video transmission between two people.


If needing documents written, please note a $120 fee is charged per page.


Please see the Zoom / Google Meets security page for more information. However, as with all forms of internet communication, if someone has access to your Zoom / Google Meets login details or has installed a virus on your computer, then it is possible your Zoom / Google Meets transmission can be compromised. is not responsible or liable for compromised Zoom / Google Meets communication between you and your counsellor.

It is VERY important you keep your Zoom / Google Meets login details secure and private, and routinely check your computer system for viruses and trojans.

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